Connecticut Form A 62 ≡ Fill Out Printable PDF Forms Online

Connecticut Form A 62 PDF Details

The Connecticut Form A 62 is a form that must be filed with the Department of Revenue Services by any person who has participated in an out-of-state transaction. The form is required for any type of income, including but not limited to wages, salary, pensions, retirement benefits and Social Security benefits. The Connecticut Form A 62 contains information about the individual's employer or payer, as well as their address outside of Connecticut. They will also complete line 7 on this page which asks if they are subject to withholding of tax by another jurisdiction on all or some types of income from sources within that other jurisdiction. If so, they will need to provide their name and taxpayer ID number where tax is withheld.

Below are some specifics of connecticut form a 62. You will have the projected time you will need to complete the form and a few additional details.

Question	Answer
Form Name	Connecticut Form A 62
Form Length	1 pages
Fillable?	Yes
Fillable fields	38
Avg. time to fill out	7 min 55 sec
Other names	ct a 62, ct blasting permit form, ct application motor, ct application permit work

12

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STATE OF CONNECTICUT

DEPARTMENT OF MOTOR VEHICLES

DRIVER SERVICES DIVISION

60 STATE STREET, WETHERSFIELD, CT 06161-2530

TELEPHONE: (860) 263-5720 On The Web At ct.gov/dmv

APPLICATION FOR SPECIAL PERMIT TO

OPERATE A MOTOR VEHICLE TO AND FROM WORK

A-62 REV. 4-2010

INSTRUCTIONS:

1. Please print or type.

2. Multiple employment requires separate applications.

3. A $100.00 non-refundable application fee in the form of a check or money order payable to DMV must accompany each request for a permit.

Operation of motor vehicles requiring a CDL or used for Public Passenger Transportation is PROHIBITED under the Special Permit Program

YOUR OFFICIAL DRIVING RECORD WILL BE REVIEWED AS PART OF THIS APPLICATION.

NAME OF APPLICANT (Last, First, Middle)

DATE OF BIRTH

OPERATOR LICENSE NUMBER/STATE

SEX

M

F


MAILING ADDRESS	(Number and Street)		(City or Town)	(State)	(Zip Code)

RESIDENCE ADDRESS (If different)		(Number and Street)	(City or Town)	(State)	(Zip Code)

NAME OF EMPLOYER (If self-employed, include business name and legal proof of self-employment)

ADDRESS OF EMPLOYER

(Number and Street)

(City or Town)

(State)

(Zip Code)

OCCUPATION

HOME TELEPHONE NUMBER

( )

DAYS AND HOURS OF EMPLOYMENT (Specify A.M. or P.M.)

TO BE ISSUED A WORK PERMIT, YOUR SCHEDULE MUST BE CLEARLY IDENTIFIED, AND

MON.

TUE.

THU.

FRI.

SAT.

MAY NOT EXCEED A CONTINUOUS 12-HOUR PERIOD PER DAY.

IF YOU HAVE MORE THAN ONE PLACE OF

EMPLOYMENT, EACH EMPLOYER MUST

WED.SUN.

COMPLETE A SEPARATE APPLICATION.

What is the distance and the commuting time from your residence to your place of employment?	Is public transportation available
	from your residence to your	YES	NO
	place of employment?	YES	NO
	place of employment?
What significant hardship(s) will you suffer without a Special Operator's Permit?

What efforts have you made to obtain other transportation?

INABILITY TO CONFIRM YOUR EMPLOYMENT MAY RESULT IN DENIAL OF YOUR SPECIAL OPERATOR'S PERMIT.

PRINTED NAME OF SUPERVISOR

SIGNATURE OF SUPERVISOR

X

PRINTED JOB TITLE OF SUPERVISOR

WORK TELEPHONE

( )

NOTICE:

OATH:

Your operator's license is under suspension. If you operate any vehicle outside of the authorized hours, you may be subject to arrest. If you operate a motor vehicle for a purpose not authorized by law, a police officer may make a report to the Commissioner of Motor Vehicles and you will be subject to a civil penalty of up to $500. If your operator's license is suspended for another reason while you are in possession of this permit, the permit is revoked, and if you thereafter operate a motor vehicle you will be subject to double the penalties imposed by law. If you alter or make improper use of the permit, you will be subject to criminal penalties.

I swear or affirm under penalty of false statement in accordance with Connecticut General Statute 53a-157, and subject to penalties for perjury for a deliberate false statement, that the above information and any attachment hereto is true and correct.

PRINTED NAME OF APPLICANT

SIGNATURE OF APPLICANT

DATE SIGNED

X

DMV USE ONLY

PERMIT:

APPROVED

DENIED

DATE PERMIT ISSUED

(If Approved)

PERMIT VALID UNTIL (If Approved)

REASON FOR DENIAL

DRIVING HISTORY

NO SIGNIFICANT HARDSHIP

INELIGIBLE

OTHER (Provide Details)

AUTHORIZED SIGNATURE (DMV)

X

PRINTED NAME

DATE SIGNED

How to Edit Connecticut Form A 62 Online for Free

This PDF editor was designed with the purpose of making it as simple and user-friendly as possible. The following steps will make managing the ct blasting permit form quick and simple.

Step 1: In order to start, hit the orange button "Get Form Now".

Step 2: Now you can alter the ct blasting permit form. The multifunctional toolbar enables you to insert, remove, modify, and highlight content or perhaps carry out other sorts of commands.

The following parts will create the PDF file that you'll be completing:

stage 1 to filling in ct application permit work

In the PRINTED, JOB, TITLE, OF, SUPERVISOR SIGNATURE, OF, SUPERVISOR, X WORK, TELEPHONE NOTICE, OATH, PRINTED, NAME, OF, APPLICANT SIGNATURE, OF, APPLICANT, X D, MV, USE, ONLY DATE, SIGNED PERMIT, APPROVED, DENIED, DATE, PERMIT, ISSUED If, Approved and PERMIT, VALID, UNTIL area, jot down your information.

stage 2 to completing ct application permit work

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